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An Unusual Case of Submassive Hemoptysis
Pulmonary Vascular Disease SESSION TITLE: Thoracic Vascular Disorders SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Monday, October 24, 2016 at 11:00 AM - 12:00 PM
An Unusual Case of Submassive Hemoptysis Carly Fabrizio DO*; and Chirag Shah MD Morristown Medical Center, Morristown, NJ
PULMONARY VASCULAR DISEASE
INTRODUCTION: Hemoptysis has a wide array of etiologies. Thermal injury to the pulmonary venous musculature from radiofrequency ablation is an uncommon cause that should be part of the differential in the appropriate patient. CASE PRESENTATION: A 52-year-old female presented to our office with hemoptysis. She described frequent episodes of approximately 30 ml of bright red expectorated blood within the past 2 days without associated chest pain, lower extremity edema, dyspnea, or epistaxis. Her medical history included hypertension and atrial fibrillation (AF) for which a successful radiofrequency ablation was done 3 years prior. Her initial diagnostic evaluation included a normal chest radiograph and normal coagulation studies and platelet count. Subsequently she underwent both a diagnostic fiberoptic bronchoscopy (FOB) and chest computed tomography (CT). FOB revealed active bleeding from both the left upper and lower lobe orifices without evidence of endobronchial lesions. CT angiogram showed normal lung parenchyma and no pulmonary arterial filling defects. However, venous phase imaging showed complete obliteration of the proximal left superior pulmonary vein (PV) and severe stenosis of the left inferior pulmonary vein. Endovascular stenting was not an option so she underwent an anterior axillary thoracotomy approach to re-establish surgical patency of left superior and inferior pulmonary veins. Native atrial appendage tissue was used to reconstruct a portion of the previously obliterated proximal superior PV. At her two year followup, she remained symptom free and radiographically the left pulmonary veins remained patent. DISCUSSION: Pulmonary vein stenosis (PVS) is a rare but serious complication of ablation procedures for AF. Procedural techniques have been successfully modified to reduce the overall incidence of PVS (1-2%). Clinical presentation of PVS varies but common symptoms include dyspnea and cough while hemoptysis remains an unusual but serious complaint. Imaging techniques used to assess anatomic and physiologic impact of PVS include V/Q, CT, and MRI. Management of PVS depends on symptomatology and degree of vein injury. Treatment usually includes endovascular PV dilation with or without stenting, however we describe a rare case of complete obliteration of the proximal PV that required surgical correction. CONCLUSIONS: Hemoptysis caused by PVS from radiofrequency ablation injury is an under-recognized entity. High clinical suspicion and multimodality diagnostic imaging can lead to earlier diagnosis and treatment. Reference #1: Braun S, Platzek I, Zophel K, et.al. Haemoptysis due to pulmonary venous stenosis. Eur Respir Rev. 2014;23:170179. Reference #2: Holmes DR, Monahan KH, Packer D. Pulmonary vein stenosis complicating ablation for atrial fibrillation. JACC: cardiovascular interventions. 2009;2:267-276. DISCLOSURE: The following authors have nothing to disclose: Carly Fabrizio, Chirag Shah No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1341
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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150#4S CHEST OCTOBER 2016
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An Unusual Case of Submassive Hemoptysis Carly Fabrizio DO*; and Chirag Shah MD Morristown Medical Center, Morristown, NJ
PULMONARY VASCULAR DISEASE
INTRODUCTION: Hemoptysis has a wide array of etiologies. Thermal injury to the pulmonary venous musculature from radiofrequency ablation is an uncommon cause that should be part of the differential in the appropriate patient. CASE PRESENTATION: A 52-year-old female presented to our office with hemoptysis. She described frequent episodes of approximately 30 ml of bright red expectorated blood within the past 2 days without associated chest pain, lower extremity edema, dyspnea, or epistaxis. Her medical history included hypertension and atrial fibrillation (AF) for which a successful radiofrequency ablation was done 3 years prior. Her initial diagnostic evaluation included a normal chest radiograph and normal coagulation studies and platelet count. Subsequently she underwent both a diagnostic fiberoptic bronchoscopy (FOB) and chest computed tomography (CT). FOB revealed active bleeding from both the left upper and lower lobe orifices without evidence of endobronchial lesions. CT angiogram showed normal lung parenchyma and no pulmonary arterial filling defects. However, venous phase imaging showed complete obliteration of the proximal left superior pulmonary vein (PV) and severe stenosis of the left inferior pulmonary vein. Endovascular stenting was not an option so she underwent an anterior axillary thoracotomy approach to re-establish surgical patency of left superior and inferior pulmonary veins. Native atrial appendage tissue was used to reconstruct a portion of the previously obliterated proximal superior PV. At her two year followup, she remained symptom free and radiographically the left pulmonary veins remained patent. DISCUSSION: Pulmonary vein stenosis (PVS) is a rare but serious complication of ablation procedures for AF. Procedural techniques have been successfully modified to reduce the overall incidence of PVS (1-2%). Clinical presentation of PVS varies but common symptoms include dyspnea and cough while hemoptysis remains an unusual but serious complaint. Imaging techniques used to assess anatomic and physiologic impact of PVS include V/Q, CT, and MRI. Management of PVS depends on symptomatology and degree of vein injury. Treatment usually includes endovascular PV dilation with or without stenting, however we describe a rare case of complete obliteration of the proximal PV that required surgical correction. CONCLUSIONS: Hemoptysis caused by PVS from radiofrequency ablation injury is an under-recognized entity. High clinical suspicion and multimodality diagnostic imaging can lead to earlier diagnosis and treatment. Reference #1: Braun S, Platzek I, Zophel K, et.al. Haemoptysis due to pulmonary venous stenosis. Eur Respir Rev. 2014;23:170179. Reference #2: Holmes DR, Monahan KH, Packer D. Pulmonary vein stenosis complicating ablation for atrial fibrillation. JACC: cardiovascular interventions. 2009;2:267-276. DISCLOSURE: The following authors have nothing to disclose: Carly Fabrizio, Chirag Shah No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1341
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
1232A
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150#4S CHEST OCTOBER 2016
]